Miles for Mammograms Committee Member Application 2.0

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* 1. Name:

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* 2. What is your street address?

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* 3. City, State, Zip:

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* 4. Telephone

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* 5. E-mail:

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* 6. Occupation

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* 7. Employer

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* 8. Employer's Address

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* 9. Education Level:

Some high school

High School Graduate

Some college

Undergraduate college degree

Some Graduate Coursework

Graduate Degree or Higher

Prefer not to answer

Other (please specify)

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* 10. Professional or other Special Skills (check all that apply):

Fundraising

Event Planning

Personnel/Human Resources

Business/Finance

Marketing/Public Relations

Technology

Legal

Other (please specify)

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* 11. Professional Background (check all that apply):

Corporate

Small Business

Non-Profit

Government

Healthcare

Other (please specify)

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* 12. Other committees or boards you have served on with dates (current & past):

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* 13. Other volunteer activities/projects, community and non-profit affiliations:

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* 14. Special Interests or Hobbies:

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* 15. Why are you interested in Serving on the Miles for Mammograms Committee?

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* 16. Can you commit to attending monthly Miles for Mammograms Meetings from March - mid-August?

Yes

Unsure

Other (please specify)

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* 17. Can you commit to attending weekly Miles for Mammograms Meetings from mid-August through September?

Yes

Unsure

Other (please specify)

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* 18. During the weeks leading up to Miles for Mammograms (September 2023), there are many volunteer options AND day-of volunteer options. Will you be able to assist as needed (with as much advance notice as possible for a request)?

Yes

Unsure

Other (please specify)

Miles for Mammograms Committee Member Application 2.0

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* 1. Name:

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* 2. What is your street address?

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* 3. City, State, Zip:

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* 4. Telephone

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* 5. E-mail:

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* 6. Occupation

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* 7. Employer

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* 8. Employer's Address

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* 9. Education Level:

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* 10. Professional or other Special Skills (check all that apply):

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* 11. Professional Background (check all that apply):

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* 12. Other committees or boards you have served on with dates (current & past):

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* 13. Other volunteer activities/projects, community and non-profit affiliations:

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* 14. Special Interests or Hobbies:

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* 15. Why are you interested in Serving on the Miles for Mammograms Committee?

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* 16. Can you commit to attending monthly Miles for Mammograms Meetings from March - mid-August?

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* 17. Can you commit to attending weekly Miles for Mammograms Meetings from mid-August through September?

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* 18. During the weeks leading up to Miles for Mammograms (September 2023), there are many volunteer options AND day-of volunteer options. Will you be able to assist as needed (with as much advance notice as possible for a request)?

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* 19. Other information that you would like to share about yourself?

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* 20. Do you know anyone affiliated with the the Family HealthCare Clinic or the Miles for Mammogram Committee?